Provider Demographics
NPI:1730138454
Name:AUDUBON ORTHOPEDICS & SPORTS MEDICINE A PROF MEDICAL CORPORATION
Entity Type:Organization
Organization Name:AUDUBON ORTHOPEDICS & SPORTS MEDICINE A PROF MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:WARREN
Authorized Official - Middle Name:ROGER
Authorized Official - Last Name:BOURGEOIS
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:504-455-0093
Mailing Address - Street 1:3939 HOUMA BLVD
Mailing Address - Street 2:SUITE 18
Mailing Address - City:METAIRIE
Mailing Address - State:LA
Mailing Address - Zip Code:70006-2931
Mailing Address - Country:US
Mailing Address - Phone:504-455-0093
Mailing Address - Fax:504-454-3964
Practice Address - Street 1:3939 HOUMA BLVD
Practice Address - Street 2:SUITE 18
Practice Address - City:METAIRIE
Practice Address - State:LA
Practice Address - Zip Code:70006-2931
Practice Address - Country:US
Practice Address - Phone:504-455-0093
Practice Address - Fax:504-454-3964
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-09
Last Update Date:2008-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA5B522Medicare PIN
LA0748110001Medicare NSC